PT. SIMEX

{{ word[lang].formTitle }}

{{ word[lang].formDescription }}

{{ word[lang].reporterIdentity }}

{{ word[lang].reporterName }} *

{{ word[lang].reporterType }} *

{{ word[lang].instituteName }} *

{{ word[lang].address }}

{{ word[lang].phoneNo }} *

{{ word[lang].email }} *

{{ word[lang].patientIdentity }}

{{ word[lang].patientInitial }} *

{{ word[lang].city }} *

{{ word[lang].age }} *

{{ word[lang].bodyWeight }} *

{{ word[lang].gender }} *

{{ word[lang].job }}

{{ word[lang].tribe }}

{{ word[lang].primaryDisease }} *

{{ word[lang].productInformation }}

{{ word[lang].productName }} *

{{ word[lang].dosageForm }} *

{{ word[lang].batchNo }} *

{{ word[lang].expiredDate }} *

{{ word[lang].dose }} *

{{ word[lang].usage }} *

{{ word[lang].adverseEvent }}

{{ word[lang].reaction }} *

{{ word[lang].usingDate }} *

{{ word[lang].reactionDate }} *

{{ word[lang].duration }} *

{{ word[lang].actionTaken }} *

{{ word[lang].didAbate }} *

{{ word[lang].didRecure }} *

{{ word[lang].alergicHistory }}

{{ word[lang].illnessHistory }}

{{ word[lang].otherInfo }}

{{ word[lang].afterReaction }} *

{{ word[lang].otherMeds }}

{{ word[lang].documentation }} *

{{ word[lang].uploadNote }} {{ word[lang].uploadNoteRed }}

{{ word[lang].submitNote }}